脑干海绵状血管瘤的显微手术治疗

目的探讨脑干海绵状血管瘤的诊断和治疗经验。方法本组18例脑干海绵状血管瘤中,病灶位于一侧大脑脚3例,桥脑及桥脑臂9例,桥脑一延髓4例,延髓2例。分别采用经幕下小脑上人路、一侧颞枕小脑幕人路、桥小脑角人路和枕后正巾人路显微手术治疗。结果血管瘤镜下全切17例,次全切除1例。眩晕病人术后症状明显减轻,除1例术后新出现复视外,其余颅神经损害患者症状减轻,或无变化。结论显微手术治疗脑干海绵状血管瘤是可行的,早期手术可能取得较好的效果。     

脑干海绵状血管瘤的显微外科治疗(附10例报告)

目的分析脑干海绵状血管瘤的显微外科治疗方法和预后。方法显微手术切除脑干海绵状血管瘤10例,病灶位于桥脑8例,延髓2例。6例桥脑、延髓背侧的海绵状血管瘤,采用枕下正中经四脑室底入路切除; 4例桥脑外侧和腹外侧的海绵状血管瘤,采用枕下乙状窦后入路切除。结果病灶均镜下全切除,病理证实为海绵状血管瘤。4例患者术后症状明显改善,5例患者出现不同程度并发症,在1周至3个月内恢复,1例患者术后因肺内感染死亡。患者术后随访3-58个月,复查MRI均未发现病灶复发,无其他并发症出现。结论在正确选择适应证的前提下,脑干海绵状血管瘤的显微外科治疗效果良好。     

显微手术治疗脑干海绵状血管瘤的临床分析

目的 探讨脑干海绵状血管瘤的显微手术治疗方法及其疗效。方法 回顾性分析2011年10月至2015年9月显微手术治疗的19例脑干海绵状血管瘤的临床资料,其中桥脑12例,中脑4例,延髓2例,桥脑延髓交界区1例。经坐位枕下后正中小脑延髓裂入路12例,坐位乙状窦后入路4例,坐位后正中幕下小脑上入路2例,翼点入路1例。结果 病灶全切除17例,次全切除2例。术后症状改善16例,无明显变化3例,无手术死亡病例。术后随访14~58个月,次全切除2例均复发并行二次手术;术前KPS评分为（75±6）分,术后KPS评分为（84±8）分,随访1年KPS评分为（90±5）分。结论 应根据术前影像学检查以及术者经验及习惯选择手术方式,坐位可以作为大部分脑干海绵状血管瘤的常规手术体位;显微手术治疗脑干海绵状血管瘤应在保证安全的前提下做到全切除,使患者获得良好预后。     

桥脑海绵状血管瘤手术指征和入路选择（附12例报告）

目的探讨桥脑海绵状血管瘤的手术指征和手术入路。方法显微手术切除桥脑海绵状血管瘤12例。11例位于桥脑背侧的海绵状血管瘤,采用枕下正中经菱形窝入路切除;1例位于桥脑腹外侧的海绵状血管瘤,采用枕下经乙状窦后入路切除。结果均镜下全切除病灶,术后病理证实为脑海绵状血管瘤。术后临床表现改善者6例,3例无变化;1例术后面瘫加重;1例术后出现外展神经瘫痪;死亡1例。术后3个月,9例MRI复查,均未见病灶,脑干组织影像学修复良好。结论正确选择手术指征和手术入路,采用显微外科技术切除桥脑CM是安全和有效的。     

脑干海绵状血管瘤手术入路选择

目的探讨脑干海绵状血管瘤手术适应证和手术入路的选择。方法回顾分析70例手术治疗的脑干海绵状血管瘤，其中位于：中脑15例、中脑-桥脑交界8例、桥脑34例、桥脑-延髓交界5例、延髓8例。我们共采用8种手术入路：经菱形窝27例、颞下或颞-枕入路14例、远外侧经髁7例、外侧小脑上幕下7例、中线小脑上幕下8例、枕经天幕4例、乳突后2例，以及眶颧1例。结果本组病例的年出血率为2．9％（77／2364），占同期颅内海绵状血管瘤的44％（70／159）；97％的病例手术选择在亚急性或慢性期、且所有患者均有颅神经症状和（或）运动功能障碍、感觉障碍、共济失调（包括失平衡）。中脑病变手术入路选择以中线小脑上（46．7％，7／15）、颞下或颞-枕（26．7％，4／15）为主；桥脑病变多选择菱形窝（58．8％，20／34）、颞下或颞-枕（23．5％，8／34）；而病变位于延髓者以远外侧经髁（62．5％，5／8）和菱形窝入路（37．5％，3／8）为主。结论脑干海绵状血管瘤表现为进行性神经功能缺失、具有占位效应、接近脑干表面者可考虑手术治疗；个体化地选择手术入路、术中神经电生理监测以及直接的电刺激是手术成功的关键。     

显微手术切除脑干海绵状血管瘤

目的 探讨显微手术切除腩十海绵状血管瘤的时机、方法和预后.方法 回顾性分析显微手术切除及病理证实的10例脑干内海绵状血管瘤的临床资料.所有病例均行CT及MRI检查.海绵状血管瘤位丁中脑1例、桥脑7例、延髓2例.采用颞下入路切除中脑海绵状血管瘤1例;乙状窦后入路切除桥腑海绵状血管瘤3例;枕下中线经第四脑室入路切除延髓海绵状血管瘤2例、桥脑海绵状血管瘤4例.采用GOS分级对于术结果进行评估.结果 显微镜下将肿瘤全切,无手术死亡.10例患者均获得随访,随访时间3-48个月(平均18.5个月).术后3个月GOS分级:Ⅴ级5例,Ⅳ级5例;术后1年GOS分级:Ⅴ级8例,Ⅳ级2例.无再出血者.结论 显微外科手术是治疗脑干内海绵状血管瘤的有效方法,远期效果满意.     

小脑延髓裂入路治疗桥臂区海绵状血管瘤3例

目的总结经小脑延髓裂入路切除桥臂区海绵状血管瘤的经验。方法 3例桥臂区海绵状血管瘤均行枕下后正中入路,分开病变侧小脑延髓裂,切除病变,并送病理检查。结果 3例海绵状血管瘤均完整切除,术后病人原有症状均明显改善,无并发症发生。结论经小脑延髓裂入路切除桥臂区病变是安全、可行的。     

桥脑海绵状血管瘤的显微手术治疗

目的 探讨桥脑海绵状血管瘤（CA）的手术治疗及其疗效。方法 2009年1月至2016年1月显微手术切除桥脑CA 9例,其中桥脑上端腹内侧1例采用颞下切开小脑幕入路,桥脑腹外侧3例采用同侧乙状窦后入路,桥脑桥臂2例采用乙状窦后经三叉神经根部周围安全区入路,第四脑室2例均采用枕下后正中入路,左侧桥脑与延髓交界区1例采用远外侧入路。结果 病灶全切8例,次全切1例;全切率为88.9%。术后7例神经功能改善,1例无变化,1例外展受限和面瘫加重;无死亡病例。术后平均随访26.3个月,次全切1例术后5年内发生再出血。结论 桥脑CA展神经功能受损和面瘫恢复较差,面部、躯体感觉障碍以及共济失调术后恢复较好;桥脑出血较少遗留明显肢体运动障碍,仅表现为下肢肌力减退;乙状窦后经三叉神经根部周围安全区入路,对同时凸向第四脑室底部和脑桥侧方的病灶其效果优于经第四脑室底入路。     

脑桥海绵状血管瘤的显微手术治疗

目的探讨脑桥海绵状血管瘤的手术治疗。方法回顾性分析9例显微外科手术切除脑桥海绵状血管瘤病人的临床资料,术中均采用神经电生理监测,根据病变部位选择手术入路,采用颞下切开小脑幕入路3例,乙状窦后入路5例,枕下后正中经小脑延髓裂入路1例。结果病变达显微镜下全切除8例,部分切除1例。术后并发轻度脑干水肿2例,视物重影2例。随访6个月,MRI复查未见肿瘤复发及新发出血。术后3个月KPS评分90分7例,80分2例。结论对有明确手术指征的脑桥海绵状血管瘤,在出血后2～4周选择合适的手术入路,在神经电生理、神经导航辅助下切除血管瘤可取得良好手术效果。     

脑干海绵状血管瘤的手术入路选择

目的 探讨脑干海绵状血管瘤的手术适应证和手术入路选择. 方法 回顾性分析51例显微手术治疗脑干海绵状血管瘤的临床资料.中脑海绵状血管瘤9例,间脑-中脑交界处1例,中脑-桥脑交界处2例,桥脑海绵状血管瘤33例,延髓海绵状血管瘤4例,桥脑-延髓交界处2例.49例亚急性手术,2例慢性期手术. 结果 术中均采用神经电生理监测引导手术,11例采用神经导航定位.根据肿瘤的部位选择手术入路.肿瘤全切49例,2例次全切,肿瘤全切除率为96.1％.术中19例伴有明显的静脉畸形,予以保护.神经功能障碍改善23例,无明显变化25例,术后症状改善和稳定率为94.1％(48/51).无手术死亡. 结论 正确选择手术适应证和个体化选择手术入路,术中神经电生理监测和神经导航辅助手术,有助于提高肿瘤全切除率.     

Virtual endoscopy assisted pure ventriculoscopic resection of cavernomas occluding foramen of Monroe: Technical note and literature review

ObjectiveCavernomas at Foramen of Monroe (FoM) are rare cases among the intracranial cavernomas. Pure ventriculoscopic removal of cavernoma at FoM through a single burr hole is challenging and rarely reported.MethodsWe herein introduced the virtual endoscopy (VE) assisted ventriculoscopic resection to treat the cavernomas at FoM. Two cases diagnosed with cavernomas at FoM, a 31-year-old male patient (case 1) and a 26-year-old male patient (case 2), were included. Both of them suffered from headache, nausea and vomiting. The pre-operative MRI revealed masses at the FoM. We reconstructed the VE on a free and open-source platform (3D Slicer) for the pre-surgical evaluation. And then ventriculoscopic operation through a single burr hole was made to remove the cavernomas at FoM.ResultsThe VE displayed a 14×19×16 mm lesion in case 1 and an 18×20×29 mm lesion in case 2 and both cases revealed some attachment between the lesions and the periventricular tissue. The ventriculoscopic operations indicated by VE were performed to achieve total resection of the cavernomas without neurological deficit.ConclusionsAlthough the neuroendoscopic treatment to cavernoma at FoM through a single burr hole was rarely reported among the previous literatures, it was a quite effective and useful method in our cases. And the application of VE before ventriculoscopic operation could help to provide a three-dimensional and panorama view of the intraventricular lesions.     

幕上与癫痫有关的海绵状血管瘤的显微外科治疗

目的 探讨幕上表现于癫痫的颅内海绵状血管瘤外科治疗方法和效果.方法 25例幕上表现于癫痫的颅内海绵状血管瘤患者,根据术前影像学、脑电图表现与运动区的关系分为A、B二组.手术在皮层脑电图(ECoG)监测下进行,包括单纯切除血管瘤、切除血管瘤和切除含铁血黄素层,以及辅助部分皮层痫灶切除、皮层热灼或软膜下横切等.结果 本组海绵状血管瘤均令切除,2例术后有一过性轻度肢体功能障碍,无手术死亡.随访10个月-4.5年,A组9例,Engel Ⅰ级6例;Engel Ⅱ B级2例;Engel Ⅲ级1例.B组16例,均无发作.结论 幕上与癫痫有关的海绵状血管瘤在ECoG监测下做病灶和痫灶切除,是控制术后癫痫发作的有效手段;运动区和附近海绵状血管瘤由于手术没有完全切除致痫灶可能是术后癫痫控制率差的原因.     

Transsulcal approach supported by navigation-guided neurophysiological monitoring for resection of paracentral cavernomas

Objectives

The aim of the study is to evaluate tools that can improve surgical precision and minimize surgical trauma for removal of cavernomas in the paracentral area. Moreover, the surgical strategies for the treatment of symptomatic epilepsy in cavernoma patients are discussed.

Patients and methods

Between June 2000 and July 2007, 17 patients suffering from paracentral cavernoma underwent surgery via a transsulcal approach with the aid of neuronavigation, functional mapping and neurophysiological intraoperative monitoring. To optimize outcome for procedures in the paracentral area, the hemosiderin-stained tissue was removed entirely except for a small proportion on the side of precentral gyrus.

Results

All cavernomas and their adjacent sulci could be precisely located with the aid of ultrasonography-assisted neuronavigation. By combining preoperative fMRI and intraoperative neurophysiological monitoring, including SEP, MEP and cortical mapping, the motor cortex could be defined in all cases. Thus damage to the primary motor area could be avoided during resection of cavernomas. All the lesions located in the paracentral area were removed completely via transsulcal microsurgical approach without neurological deficits. No significant seizures were induced during surgery.

Conclusions

The successful excision of these lesions was effected by the following four key factors: (1) the precise location of the lesion supported by intraoperative neuronavigation; (2) the preservation of the eloquent area with the aid of functional mapping; (3) a minimally invasive transsulcal microsurgical approach; and (4) the entire removal of cavernoma and hemosiderin-stained tissue.     

Analysis of factors influencing the prediction of surgical treatment for symptomatic temporal lobe epilepsy

The results of treatment were analyzed in 37 patients with drug-resistant symptomatic temporal lobe epilepsy among whom there were 22 patients with low-grade intracellular tumors, 2 with cavernomas; 6 with cortical malformations, and 9 with residual organic lesions. Double pathology was noted in 4 patients. Mono- and multiregional lesions were observed in 30 cases. Removal of the site of lesion, extended medial resections, and temporal lobectomy were performed in 7, 5, and 25 cases, respectively. There was an association of the quality of outcomes with the scope of an intervention: the best results were achieved when the affected area with adjacent cortical portions was completely removed within the eliptogenic area. Resections for multiregional lesions are low effective.     

神经导航辅助显微手术在神经外科中的应用

目的：探讨神经导航技术在神经外科领域的应用前景和总结应用神经导航辅助显微神经外科手术切除位于脑重要功能区和深部小病灶的经验和体会。方法：我院2000年11月至2001年3月采用StealthStation神经导航系统辅助显微手术切除的颅内病灶18例,额叶6例（其中3例为于运动区）,顶叶4例,枕叶2例,颞叶1例,桥小脑角2例,小脑半球3例,脑膜瘤6例,胶质瘤4例,炎性肉芽肿2例,血管网织细胞瘤3例,脂肪瘤,三叉神经纤维瘤和寄生虫感染各1例,结果：神经导航总体误差1．8－5．7mm,平均2．8mm,病灶全切除14例,次全切4例,位于运动区的3例小病灶,手术全切除后无任何神经功能障碍,结论：Stealth Station神经导航系统定位准确,尤其是对位于脑深部和重要功能区的小病灶,辅助显微手术效果显。     

神经内镜经双鼻孔入路切除侵袭性垂体腺瘤的临床疗效分析

目的探讨神经内镜下经双鼻孔入路切除侵袭性垂体腺瘤的临床疗效及安全性。方法回顾性分析38例经双鼻孔蝶窦入路内镜下切除侵袭性垂体腺瘤患者的临床资料;总结分析其临床疗效、并发症和优势。按Knosp分级,Ⅲ级者28例、Ⅳ级者10例。结果本组患者中肿瘤全切除者18例、次全切除者12例、部分切除者8例。术后视力视野改善者22例,有效率为81.5%(22/27例);头痛缓解者11例,有效率为78.6%(11/14);内分泌功能障碍缓解9例,有效率为81.8%(9/11)。术后并发尿崩症者17例(44.7%)、脑脊液鼻漏1例(2.6%)、颅内感染1例(2.6%),行鞍区血肿清除术1例,无死亡病例。10例患者术后行放疗,2例患者行药物治疗。结论经双鼻孔入路内镜下切除侵袭性垂体腺瘤的肿瘤切除率高、创伤小、并发症发生率低,同时提高了手术的安全性和有效性。     

Magnetoencephalography (MEG) predicts focal epileptogenicity in cavernomas

OBJECTIVE: The aim of this study was to identify the irritative epileptic zone in patients with cavernomas by means of magnetoencephalography (MEG). METHOD: Among 82 patients operated for epilepsy, whose presurgical evaluation had included MEG, histological assessment of the tissue removed had confirmed cavernomas in eight. These eight patients had epilepsy since 18.6 (SD 12.7) years on average. The monitoring lasted about 2.1 (SD 1.3) hours and a median 20.9 (SD 14.3) spikes per hour were recorded. Spontaneous brain activity was recorded by means of a 74 channel dual unit MEG system (Magnes II, 4-D Neuroimaging) with simultaneous EEG recording (31 scalp electrodes). Spike analysis was performed using different source (moving dipole, current density reconstruction) and head models (spherical shells, BEM). Co-registration of neurophysiological and imaging data (MRI) was based upon anatomical landmarks. RESULTS: In 6/8 patients co-localisation from the cavernoma and epileptic zone was found. In two patients the focus was localised in the parieto-occipital lobe, in three patients in the frontal lobe and in three patients in the temporal lobe. In one case of temporal and one case of frontal lobe focus localisation there was no spatial relationship to the cavernoma. CONCLUSION: In cases of focal seizures due to a single cavernoma, MEG may precisely delineate the epileptogenic tissue bordering the lesion. In patients with multiple cavernomas or dual pathology, MSI may reveal the complexity of the case, and contribute to the decision about further invasive diagnostics and more sophisticated therapeutic measures. MEG is a promising method for prediction of the epileptic zone in cavernoma related epilepsies, and thus it can contribute to decision making about and planning of epilepsy surgery.     

脑内小病灶立体定向直视手术—82例临床分析

目的：应用立体定向直视手术，摘取颅内小病灶。方法：ＣＴ导向立体定向技术开颅治疗脑内小病灶８２例。其中额叶４２例，顶叶３４例，顶枕部４例，侧脑室１例，丘脑１例。临床表现以癫痫为主７５例，偏瘫２７例，偏身感觉障碍２１例，语言障碍１６例。采用ＣＴ导向立体定向显微直视手术切除病灶。结果：７９例术后神经损害症状消失，３例明显减轻，无新的神经损害症状，无手术并发症及手术死亡。结论：该方法是一种微侵袭手段     

经胼胝体入路切除第三脑室肿瘤

目的 探讨31例第三脑室内肿瘤经胼胝体入路手术治疗的临床与神经心理结果.方法 31例第三脑空前部肿瘤采用经胼胝体-穹隆问、胼胝体-窒问孔、胼胝体-脉络膜裂结合室问孔入路手术治疗,患者在术前和术后用Rancho Los Amigos认识功能评定量表进行神经心理测试,术后行影像学复杏和GOS评估.结果 采用纵裂胼胝体-室间孔入路14例,纵裂胼胝体-穹降间入路12例,纵裂胼胝体一脉络膜裂(脉络膜上、下)结合室间孔入路5例;全切26例,次全切除5例.手术死亡1例.8例垂体柄因肿瘤侵犯被切除后尿崩7例,5例完全恢复,2例持续尿崩.Rancho LosAmigos认识功能评定术后有明显改善.84%(26/31)术后GOS评估优秀(V级).术后2例出现意识障碍超过24 h,约72 h恢复.术后2例出现失联系综合征,1例有明显记忆障碍,经康复治疗有好转.结论 主体位于第三脑室内、后界末达到松果体的肿瘤都可以经上述胼胝体入路进行手术切除.选择经室间孔、经穹隆间、经脉络膜上下进入第三脑室可因病变的具体方位和周围血管布局而定.但是胼胝体、穹降问、脉络膜上下可以切开的范围有限且值得进一步探讨,严格切开范围和控制牵拉幅度可以最大限度减少脑功能损害.